NURSING CARE OF THE MAN UNDERGOING PROSTATECTOMY

PREOPERATIVE NURSING CARE

Assess the mans and familys knowledge about the surgery. Some men are confused about the surgical approach, because there are several, quite different, methods. Inform the man that he will have a urinary catheter when he returns from surgery, and he may have a drain(s) in his incision. He also will be wearing sequential pneumatic compression stockings. This knowledge can reduce anxiety postoperatively and increase cooperation with postoperative care. Ensure that a signed consent form is in the chart and that all other preoperative tasks outlined in Chapter 7 are done. Bowel preparation with a 2% neomycin enema may be ordered. This cleanses the bowel if a perineal approach will be used. Communicate willingness to address any concerns or anxiety. Men may be anxious about the outcome of their surgery and potential long-term effects of the surgery on their sexuality.When a prostatectomy is performed for prostate cancer, additional fears include the extent of the cancer and surgery, chances for cure, and possible end-of-life issues. risk for hemorrhage and other postoperative complications. Vital sign changes may be early manifestations. Maintain accurate intake and output records, including amounts of irrigating solution used.Frequently assess patency of any catheters and drains. Monitor color and character of urine. Catheters may become occluded by blood clots or kinks, interfering with urinary drainage and increasing the risk of hemorrhage. Assess and manage the mans pain. The man may have at least three types of pain: incisional pain, bladder spasm, and abdominal cramps due to intestinal gas. Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) are administered on a routine and prn basis to control incisional pain. Bladder spasms may be accompanied by strong urges to void and urine leakage around the catheter. Belladona and opium (B & O) suppositories may be used to relieve bladder spasms. Maintain antiembolic stockings and pneumatic compression devices as ordered. Assist with leg exercises and ambulation as ordered, usually the first postoperative day. The man who has had prostate surgery is at risk for developing thromboemboli; these are important preventive measures. Encourage the man to maintain a liberal fluid intake of 2 to 3 L a day. Increased fluids reduce burning on urination after catheter removal and the risk of urinary tract infection. (continued)

POSTOPERATIVE CARE
Maintain the usual postoperative assessments (see Chapter 7) and follow aseptic techniques in urinary drainage and irrigation care. Monitor vital signs closely for the first 24 hours and regularly thereafter. The man who has had prostate surgery is at

NURSING CARE OF THE MAN UNDERGOING PROSTATECTOMY

The Man with a Transurethral Resection of the Prostate (TURP)
For the first 24 to 48 hours, monitor for hemorrhage, evidenced by frankly bloody urinary output, presence of large blood clots, decreased urinary output, increasing bladder spasms, decreased hemoglobin and hematocrit, tachycardia, and hypotension. Notify the physician if any of these manifestations occur. Postoperative hemorrhage may be either arterial or venous, and may be precipitated by movement, bladder spasms, or an obstructed urinary drainage system. Instruct the man with a three-way indwelling catheter with traction to keep the leg straight while the traction is applied. A No.18 to 22 Fr three-way catheter with a 30 to 45 mL balloon usually is inserted following a TURP. The inflated balloon is pulled down into the prostatic fossa and the catheter tubing is pulled down and taped to the mans leg to apply pressure against the operative site, preventing bleeding. Explain that the presence of a urinary catheter will cause the sensation of needing to void, but it is important not to strain to try to void around the catheter or when having a bowel movement. Explain that bladder spasms, experienced as lower abdominal pressure or pain and a desire to urinate, may occur. Ensure that the man understands that this is an expected sensation, and that medications can help alleviate this discomfort. Pressure on the urethra by the large catheter and on the internal sphincter by the catheters balloon stimulate the micturition reflex. Straining to void or to have a bowel movement may stimulate bladder spasms and increase pain; it also may increase the risk for bleeding. Administer pain medications at regular intervals. If the man has a continuous bladder irrigation (CBI), assess the catheter and the drainage tubing at regular intervals. Maintain the rate of flow of irrigating fluid to keep the output light pink or colorless. Assess the urinary output every 1 to 2 hours for color, consistency, amount, and presence of blood clots; assess for bladder spasms. CBI is used to prevent the formation of blood clots, which could obstruct urinary output. Bladder distention resulting from output obstruction increases the risk of bleeding. Irrigating fluids are continuously infused and drained at a rate to keep urine light pink or colorless. Urine that is frankly bloody, contains many blood clots, or is decreased in amount, as well as bladder spasms, are indicators of obstruction and bleeding. Assess for fluid volume excess and hyponatremia, called TURP syndrome, which is manifested by hyponatremia, decreased hematocrit, hypertension, bradycardia, nausea, and confusion. If these manifestations occur, notify the physician. TURP syndrome results from the absorption of irrigating fluids during and after surgery. Untreated, it may result in dysrhythmias, seizures, or both. If the man does not have CBI, follow agency procedure and physician orders for irrigating the indwelling catheter (usually when the urine is frankly bloody or has numerous larger blood clots, or when bladder spasms increase). In most in-

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stances, using sterile technique, the catheter is gently irrigated with 50 mL of irrigating solution at a time, until the obstruction is relieved or the urine is clear. Ensure equal input and output of irrigating fluid. Intermittent irrigation may be used to prevent obstruction of urinary drainage. Following catheter removal, assess the amount, color, and consistency of urine. Explain that the man may experience burning on urination, that dribbling after urination is a common experience, and that the urine may contain small blood clots after catheter removal. The CBI and catheter usually are removed in the 24 to 48 hours following surgery. Urinary control may be improved by teaching the man to start and stop the urine stream several times during each voiding and by practicing Kegel exercises. Regaining full control may take up to 1 year.

The Man with a Retropubic Prostatectomy

Assess the abdominal incision for the presence of urine. As the bladder is not entered during a retropubic prostatectomy, no urine should be found on the dressing. Assess the abdominal incision for increased or purulent drainage, and the man for an increased temperature and pain. These manifestations indicate the presence of infection.

The Man with a Suprapubic Prostatectomy

Assess urinary output from both the suprapubic and the urethral catheters. The man with a suprapubic prostatectomy often has two separate closed drainage systems: one from the suprapubic incision and one from a urethral catheter. Assess the abdominal dressing for urinary drainage, and change saturated dressings frequently. Consult with a skin care specialist if necessary. Urine is highly irritating to the skin. Following removal of the urethral catheter (usually 2 to 4 days after surgery) and based on physician orders, clamp the suprapubic catheter and encourage the man to void. Assess residual urine by unclamping the suprapubic catheter and measuring urinary output after voiding. If residual urine is 75 mL or less with several voidings, the suprapubic catheter is removed.

The Man with a Perineal Prostatectomy

Assess perineal incision for drainage and manifestations of infection. Location of the incision in the perineum increases the risk of infection. Do not take rectal temperatures or administer enemas. Insertion of a thermometer or enema tubing into the rectum may precipitate bleeding. Use a T-binder or padded scrotal support to hold the dressing in place. Following removal of the dressing and perineal sutures, heat lamps or sitz baths may be used. The location of the dressing makes application difficult: Heat lamps or sitz baths provide heat and promote healing. Teach the man to perform perineal irrigations with sterile normal saline as ordered and after each bowel movement. Because of the proximity of the incision to the anus, special wound care is necessary to prevent infection.